December 02, 2012

Consulting a Specialist

My tag-line that follows my signature on Veterinary
Information Network is “I’m lost, but I’m making good time.” When I am putting
a puzzling case up for consultation, I have already done one of two
things. One is, I’ve done everything I
know how to do, and I’m still stumped.
The second is, I’ve reached a crossroads in the diagnostic plan and I
don’t want to put the patient through unnecessary testing. Therefore, I want
some input into the best choice as I proceed.

After thirty-four years of doing this, I’m able to handle
the majority of cases that walk through my door. On the other hand, I certainly still have not
“seen it all” (and majority means “more than half”). Of course, it’s impossible to have the expert
knowledge of a specialist in every field.
There are no “experts on everything”, though are some people who have
that opinion of themselves.

Some things seem obvious.
If I have a terrible eye problem, I want to see an ophthalmologist.

Some are not so obvious.
If I go to my primary care doctor because I feel bad, I expect him to
examine me and make a diagnosis that will enable effective treatment. When the physical exam and history don’t give
him enough information to make the diagnosis, I expect him to perform
diagnostic testing.

If he still doesn’t know what is going on, I expect him to
refer me to someone with more specialized expertise. I really don’t want him to just spitball it
and prescribe some medicine just to get me out of the office.

While we are told that seventy percent of our patients will
get well if we can manage not to screw them up (i.e. they don’t really need us), still
there are those thirty percent that need help.
If I’m one of those, I want the level of help that I need.

For the first two decades of my professional career, I didn’t
have the option to refer many patients.
The nearest referral specialists were at the veterinary teaching
hospital at the University of Missouri – three hundred miles away. Most of my clients couldn’t or wouldn’t make
the trip. “What can you do here?” Well, I can do my best, but I don’t have the expertise
and equipment of the specialists who are teaching at the veterinary
school.

Because of this, I attempted procedures that I would rather
have referred. Sometimes they turned out
very well, and I learned some techniques that I never would have tried, had the
referral option been available. Of
course, sometimes they didn’t turn out so well, but with euthanasia being the
only alternative, we gave it a shot.

I generally try to avoid catch-phrases like “paradigm shift”. So I won’t say that. I will say that today’s new veterinarians
have a completely different mindset about the general practitioner’s scope of
practice than we did, lo, these many years ago.

Back when dinosaurs walked the earth, a veterinarian was
more or less expected to do it all. Come
in from delivering a calf by C-section, diagnose a horse’s lameness problem,
then perform orthopedic surgery to fix a dog’s fractured leg. I have known many veterinarians who did all
that. Some managed to be better than
good at all of it. Most had their areas
of strength and weakness, and eventually
would shift their activities to their strengths. The problem was, you might be the only game
in town. If you tell people that you
aren’t a good man for their problem, you need to have a name for them to
call. When that was not the case, you
just had to be honest and say, “This is really not the best way to handle this
case, but it is all I have to offer you.
The animal really needs…”

The important thing was to do your best and be honest with
the client. That hasn’t changed. What has changed is the increased availability
of specialists, and the increased availability of attorneys.

Today’s veterinary students are encouraged to refer anything
complicated to a specialist. The problem
is the definition of “complicated”.
Where do you draw the line? When
do you learn some new skill?

A new veterinarian has some of the same problems I did. Every case you see is your first one. I was on the phone back to my professors
almost every day when I first got out on my own. The new generation also has the specter of
being admonished to offer referral for almost EVERYTHING, lest one be liable
for a malpractice suit. The faculty put
the fear of God into them on this subject.

I’m fortunate to have a group of referral specialists only
ONE hundred miles away now, and they are some really good doctors. Still, they are a hundred miles away, and
they aren’t cheap. That means that for
many complicated cases, I can’t put the monkey on somebody else’s back. I’m still in the position of having to do my
best right here.

There is hardly a week that goes by that I am not emailing
or telephoning more than one specialist about my cases. When I have reached my limitations, I know
it, and I do my best to get more help for my patients.

What brings this subject to mind was an interesting
experience I had this past week. I was
called to testify in a neglect case involving an apparently starving
horse. The horse was emaciated and very
weak. It looked like a skeleton with
skin. The owner had sought no medical attention for the horse, and stated that
he STILL would not have done so, if not for pressure from the Sheriff’s
department.

Now there are only two basic things that can be going on
here. Either the horse didn’t get enough
nutritious food, or it had such a severe medical problem that the food could
not be utilized. This is not rocket science.
In either case, the horse’s care has been neglected. It’s a no-brainer.

In court, the defendant objected to my being called as a
witness because I am not a specialist in equine medicine. He had been looking at my website and blog
and found “my own admission” that I often consulted specialists when I had a
case beyond my expertise. In his mind,
that makes me unqualified.

By contrast, his defense was “I’ve done everything I know
how to do, but the horse just keeps losing weight.” He did NOT seek help or advice, despite the
obviously deteriorating situation. He just
kept on doing “everything he knew how to do”, even though it was not working.

If he had spent half as much time researching how to care
for his horse as he had on trying to undermine my credibility, he wouldn’t have
been in court in the first place.

When your veterinarian says that he (or she) needs to
consult a specialist, or wants to refer you to a specialist, I see that as the
mark of a responsible doctor, not a declaration of incompetence. If I need a cardiac bypass, I don’t want my family
doctor to learn on me.

Side note: The horse
was confiscated and has been gaining weight, and is feeling much better since
getting adequate feed in the last two week.
There is good reason to hope for a happy ending here.